Consensus statement on the content of clinical reasoning curricula in undergraduate medical education.

INTRODUCTION: Effective clinical reasoning is required for safe patient care. Students and postgraduate trainees largely learn the knowledge, skills and behaviours required for effective clinical reasoning implicitly, through experience and apprenticeship. There is a growing consensus that medical schools should teach clinical reasoning in a way that is explicitly integrated into courses throughout each year, adopting a systematic approach consistent with current evidence. However, the clinical reasoning literature is 'fragmented' and can be difficult for medical educators to access. The purpose of this paper is to provide practical recommendations that will be of use to all medical schools. METHODS: Members of the UK Clinical Reasoning in Medical Education group (CReME) met to discuss what clinical reasoning-specific teaching should be delivered by medical schools (what to teach). A literature review was conducted to identify what teaching strategies are successful in improving clinical reasoning ability among medical students (how to teach). A consensus statement was then produced based on the agreed ideas and the literature review, discussed by members of the consensus statement group, then edited and agreed by the authors. RESULTS: The group identified 30 consensus ideas that were grouped into five domains: (1) clinical reasoning concepts, (2) history and physical examination, (3) choosing and interpreting diagnostic tests, (4) problem identification and management, and (5) shared decision making. The literature review demonstrated a lack of effectiveness for teaching the general thinking processes involved in clinical reasoning, whereas specific teaching strategies aimed at building knowledge and understanding led to improvements. These strategies are synthesised and described. CONCLUSION: What is taught, how it is taught, and when it is taught can facilitate clinical reasoning development more effectively through purposeful curriculum design and medical schools should consider implementing a formal clinical reasoning curriculum that is horizontally and vertically integrated throughout the programme.

Rising to the challenge: rheumatology can lead in multi-professional education and training globally in the 21st century.

Healthcare delivery is changing, responding to needs of an ageing population with multiple long-term conditions. Safe and effective patient care in rheumatology should be delivered by a multi-professional team who understand how their roles fit individually and collectively within the team. This requires an understanding from healthcare educators and managers as to how to equip team members with the appropriate knowledge skills and behaviours, both as students and when working in clinical practice. Educational models exist that can facilitate this, and rheumatology teams in primary, community and secondary care provide an excellent opportunity to demonstrate effective team working and its impact on patient care through research and evaluation on health systems, and educational and patient outcomes.

Medical education through an invasion: insights from an elective programme for Ukrainian medical students at the University of Cambridge.

Medical students in Ukraine have faced extraordinary disruption to their clinical studies with both the COVID-19 pandemic and subsequent Russian military invasion forcing a majority of their learning to be conducted remotely. Over the summer of 2022, the School of Clinical Medicine, University of Cambridge hosted 20 medical students from Kharkiv National Medical University for a seven-week intensive clinical elective programme. The aim was to provide an immersive clinical placement that would help students to attain the necessary knowledge and experience to become competent and confident practising doctors. This perspective piece aims to support the development of future equivalent exchanges through outlining the placement's context, its planning and implementation, evidence of placement impact, and finally reflections and learning points.

Patient contact in the first year of basic medical training--feasible, educational, acceptable?

BACKGROUND: A new UK medical school uses substantial early patient contact in the first 2 years of an integrated 5-year course. AIMS: To explore the feasibility, educational effectiveness, and acceptability to patients of substantial early patient contact. METHODS: Mixed-methods case study with data from patients, students, and staff gathered via encounter forms, questionnaires, interviews, and focus groups. RESULTS: The curriculum model of recruiting a specific patient case-mix to match concurrent theoretical teaching was feasible. Patients were willing to attend specifically to meet students, even if not receiving contemporaneous care. Patient satisfaction with teaching involvement was very high, and most patients were willing to attend further sessions. Although at an early stage of knowledge and skill acquisition, students greatly valued their extensive contact with patients. They perceived it as adding substantially to their learning of clinical medicine, by providing 'real' learning opportunities and linking theory to practice. It was motivating and memorable, and enabled students to meet learning objectives. There was also evidence that it encouraged students to develop a patient-centred approach. CONCLUSIONS: Early, integrated patient contact was both feasible to organise and acceptable to patients. The curriculum model was perceived by all parties to be educationally effective. The indications are that this model will be sustainable but will need consistent intensive support.

Heat shock protein 60: identification of specific epitopes for binding to primary macrophages.

In the present study, we characterized regions of human heat shock protein (HSP) 60 responsible for binding to primary macrophages. Studies using 20-mer peptides of the HSP60 sequence to compete with HSP60-binding to macrophages from C57BL/6J mice showed that regions aa241-260, aa391-410 and aa461-480 are involved in surface-binding. HSP60 mutants, lacking the N-terminal 137, 243 or 359 amino acids, inhibited HSP60-binding to primary macrophages to different degrees, demonstrating that all three regions are required for optimal binding. Analysis of different pro- and eukaryotic HSP60 species indicated that phylogenetically separate HSP60 species use different binding sites on primary macrophages.

Identification of the heat shock protein 60 epitope involved in receptor binding on macrophages.

In the present study, we identified the human heat shock protein 60 (HSP60) epitope responsible for binding to macrophages. Studies using overlapping 15- and 20-mer peptides of the human HSP60 sequence to compete with binding of HSP60 to macrophages indicated that surface binding was accounted for by the region aa481-500. Deletion mutants of HSP60, lacking the N-terminal 137, 243 or 359 amino acids, strongly inhibited HSP60 binding to macrophages. Monoclonal antibodies addressing regions aa1-200, aa335-366 or aa383-447 did not block HSP60 binding. We conclude that a single C-terminal region, aa481-500, accounts for the binding of HSP60 to macrophages.

Arthritis associated with enteric infection.

Reactive arthritis is classically seen following infection with enteric pathogens such as Yersinia, Salmonella, Campylobacter and Shigella. Inflammatory arthritis has also been described following other enteric infection with organisms such as Clostridium difficile, Brucella and Giardia. Furthermore, arthritis is seen in Whipple's disease, caused by the actinomycete Tropheryma whippelii. This chapter reviews the current understanding of these conditions (with the exception of Brucella, which is discussed in a subsequent chapter). The epidemiology is reviewed, and the contribution of both host and organism to the aetiology and pathogenesis is discussed with particular discussion of the role of HLA-B27 in host susceptibility. Recent work exploring evidence for traffic of pathogenic organisms to the joint is highlighted. A practical approach to the diagnosis and management of the condition is then formulated based, where possible, on clinical trial evidence.

Teaching knee joint aspiration to medical students-an effective training with long-term benefits.

The objective of this study was to assess the effectiveness of undergraduate training in knee aspiration and to determine the impact this had on subsequent postgraduate clinical practice. This paper is a cohort study of undergraduate training with a cross-sectional questionnaire study of postgraduate practice. The study was held at the University of Cambridge and NHS hospitals in the Eastern Region Postgraduate Deanery (England). The main outcome measures are the undergraduate competence in practical skills in a simulated setting and the differences in postgraduate practice with or without prior undergraduate training in knee aspiration. Implementing an undergraduate training programme in knee aspiration resulted in student competence in this skill. Undergraduate teaching of knee aspiration also improved postgraduate clinical practice, significantly increasing trainee doctor confidence and also increasing the frequency with which knee aspiration was undertaken. Postgraduate reinforcement of learning was identified as an additional requirement. Undergraduate teaching of knee aspiration not only results in competent performance in end of course assessments but also improves postgraduate confidence that potentially translates into improved clinical practice.

T cell recognition of a highly conserved epitope in heat shock protein 60: self-tolerance maintained by TCR distinguishing between asparagine and aspartic acid.

Cross-reactive T cell recognition of self-heat shock proteins (hsp) has been ascribed a regulatory role in inflammatory arthritis in both animal models and human disease. The previous work implies that a repertoire for epitopes in self-hsp60 should exist in normal subjects. Accordingly, we sought to generate self-hsp60-reactive T cell clones from a healthy individual using a highly purified preparation of recombinant human (Hu) hsp60. Epitope mapping using synthetic peptides and truncated constructs indicated that the T cell clones obtained actually recognized hsp60 derived from Escherichia coli. Using a series of alanine-substituted peptides and additional appropriate synthetic peptides, it was demonstrated that the clones maintain self-tolerance because of their sensitivity to an asparagine to aspartic acid sequence difference between E. coli and HuHsp60 in the epitope-containing peptide. In addition, despite substantial conservation of sequence, the homologous peptide from HuHsp60 did not compete with the E. coli-derived peptide for recognition or antagonize responses by acting as an altered peptide ligand. The results suggest that, even when the immune system targets a highly conserved epitope in bacterial hsp60, self-tolerance is maintained. Furthermore, the finding that T cell clones specific for minor contaminant proteins in HuHsp60 preparations can readily be isolated raises the possibility that the HuHsp60 facilitates presentation of antigenic proteins to the immune system.